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Quebec Child Support Determination Form

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Quebec Child Support Determination Form
Quebec Child Support Determination Form
1
SCHEDULE I
(s. 3)
CANADA CHILD SUPPORT
Province of Québec DETERMINATION FORM
District of ________________________
FORM: father
File No. _____________________ mother
produced jointly
established by the court
prepared on_______ _______ _______
Year Month Day
Please complete in block letters
The parents may complete the form together and must provide all required documents. If they do not complete the form
together, the parent who completes the form must provide all information and documents in respect of himself or
herself. That parent may also indicate any known information about the other parent.
DO NOT STAPLE DOCUMENTS TO THE FORM
Part 1 Identification
100 Surname _______________________________________ Given name(s) __________________________
(Father’s identification)
101 Surname _______________________________________ Given name(s) __________________________
(Mother’s identification)
Indicate the date of birth of each common child of the parents in respect of whom the application is made.
102 ______ ______ ______ 104 ______ ______ ______ 106 ______ ______ ______
Year Month Day Year Month Day Year Month Day
103 ______ ______ ______ 105 ______ ______ ______ 107 ______ ______ ______
Year Month Day Year Month Day Year Month Day
Part 2 Statement of parents income
Indicate income for the current year or foreseeable income for the next 12 months, as the case may be. Provide a copy of the provincial income tax return filed in
accordance with the Taxation Act (chapter I-3) and the provincial assessment notice of the Minister of Revenue for the last fiscal year _____ or, if the income tax return
has not been filed or the notice has not been sent, provide a copy of the federal income tax return filed in accordance with the Income Tax Act (R.S.C., 1985, c. 1 (5th
Supp.)) and the federal assessment notice of the Minister of National Revenue for the last fiscal year _____. Also provide the requested documents and any other
document used to establish income.
FATHER MOTHER
200
Gross salary
(Provide the last three pay slips)
___________ ___________
201
Commissions/tips
___________ ___________
202
Net income from a business or self-employment
(Gross income less expenses relating to the business or self-employment)
___________ ___________
(Provide financial statements)
203
Employment insurance benefits and parental insurance benefits
___________ ___________
204
Support paid by a third party and received for own needs
___________ ___________
205
Retirement or disability benefits, or other benefits
___________ ___________
206
Interest, dividends, and other investment income
(Write taxable amount of dividends filed in the provincial income tax return or,
___________ ___________
where applicable, in the federal income tax return)
207
Net rentals
(Gross rental income less expenses associated with the rental of immovables)
___________ ___________
(Provide a statement of income and expenses for each immovable)
208
Other income
(Excluding family-related government transfers, last-resort financial assistance benefits
___________ ___________
and any sums granted by the Minister of Education, Recreation and Sports
under a financial assistance program for education expenses)
(Please specify: _______________________________ )
209
TOTAL
(Add lines 200 to 208)
___________ ___________
(2014-04)
Quebec Child Support Determination Form
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